Chess in Schools Application 123 Introduction:The Cris Collinsworth ProScan Fund (CCPF) is proud to provide chess in Greater Cincinnati schools. Successful implementation of the Chess in Schools Program requires collaboration between participating schools and CCPF. If you have read and agree to our pre-application checklist, please fill out the application below.School InformationSchool Name* School Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School ContactName* First Last Title* Email* Work Phone*Mobile PhoneSecondary School ContactIn case we can't reach primary contactName* First Last Email* Work Phone*Mobile Phone Program RequestPlease briefly explain why you would like to have chess at your school.*What is your school's poverty rate?* Classroom Monitor(s) Information*Please specify the staff person(s) who will be in the room with our instructor at all times. Click the + icon to add more than one.NameTitleEmail Which grade(s) will be participating? How many classes per grade?* Please indicate your preferred schedule for chess, as well as backup options.*If requesting more than one class, please include this information for each one. Upload a separate document below if needed.FileMax. file size: 100 MB. I understand that the Cris Collinsworth ProScan Fund is not responsible for:*Any/all injuries during class time; Any/all disciplinary actions; Student transportation before and after class; Student attendance; Organizing boards and pieces prior to each class Yes Notice of Photographic and Media RecordingThe Cris Collinsworth ProScan Fund reserves the right to use, print, or publish in any medium any photographs, film, videos, and all other visual media taken or produced at my school in association with the Queen City Classic Chess in Schools Program for purposes of promotional, marketing, and/or publicity materials. Yes Comment(s)Disclaimer and Signature*By submitting this application, I certify that my answers are true and complete to the best of my knowledge. Yes Please sign by typing your full name:* Today's Date* Month Day Year
